ECT and Brain Stimulation Therapies — 10-mark SAQ

Stem

A 72-year-old woman has a six-week first episode of profound depression. She believes she is dead and that her bowel has rotted, has stopped eating and drinking, is mute, holds an imposed posture and resists passive movement. She is dehydrated; sodium is 128 mmol/L. Attention fluctuates. One antidepressant was prescribed four weeks ago. Her daughter asks you to “give ECT today even if she says no.”[1][2]

Questions — exactly 10 marks

a) State the working psychiatric diagnosis and the clinical reason ECT assessment is urgent. (2 marks)

b) Give the first three management priorities while ECT is being considered. (3 marks)

c) Describe the safe conduct of one modified ECT treatment. (3 marks)

d) Give one cognitive-consent point and one relapse-prevention point. (2 marks)

Model answer and reproducible marking key

a) Diagnosis and urgency — 2 marks

1. One mark: severe major depressive episode with psychotic nihilistic/somatic delusions and catatonia. Accept “psychotic depression complicated by catatonia.” Do not award for “treatment-resistant depression”: one four-week antidepressant trial does not establish it.[1][2]
2. One mark: ECT assessment is urgent because refusal of intake has caused life-threatening physiological compromise and delay may be dangerous. Do not call this malignant catatonia from dehydration/hyponatraemia alone; reserve that term for catatonia with pronounced autonomic abnormality, typically hyperthermia and autonomic dysfunction. Suicidality or psychosis alone does not score this mark.[2][1]

Subtotal: 2/2. No half marks.[1]

b) First priorities — 3 marks

3. One mark: stabilise in parallel—restore hydration and nutrition safely, recheck/correct clinically significant electrolytes under medical supervision, assess aspiration/pressure-area/VTE risk and monitor physiology. The anaesthetist and medical team decide readiness; do not teach “ECT before sodium is corrected” as a blanket rule.[1][2]
4. One mark: investigate the late first presentation and fluctuating attention for delirium and reversible medical, neurological, medication and substance causes; the low sodium must be explained rather than dismissed by a normal CT.[2]
5. One mark: refer urgently to the ECT service while assessing decision-specific capacity and the exact local consent/legal pathway. Family request, diagnosis, incapacity or detention alone does not authorise treatment.[1]

Subtotal: 3/3. No additional mark for naming an unsourced statute.[1]

Useful but non-scoring refinement

A lorazepam challenge can support catatonia: 1–2 mg IV or IM, or 2 mg orally, reassessed at about 5, 15 or 30 minutes respectively. About a 50% reduction on a structured scale supports a response but is not perfectly specific. It must not delay urgent ECT in malignant or otherwise life-threatening catatonia.[2]

c) One modified ECT treatment — 3 marks

6. One mark: reconfirm indication, consent or lawful authority, interval events, medication/fasting plan and anaesthetic readiness; obtain IV access and use appropriate general-anaesthesia physiological monitoring plus ECT EEG.[1]
7. One mark: preoxygenate and induce general anaesthesia; after unconsciousness place the bite block, then apply and inflate an isolated arm or leg cuff above systolic pressure before neuromuscular blockade circulates, while retaining EEG monitoring. Give individualised blockade and ventilate throughout.[1]
8. One mark: deliver the prescribed brief-pulse stimulus, assess EEG morphology/generalisation and motor expression without a rigid 25-second rule, ventilate and monitor recovery including haemodynamics, prolonged seizure, delirium and cognition.[1]

Subtotal: 3/3. Naming a drug or dose is not required. If offered, the cited guideline gives propofol 0.75–1 mg/kg IV and succinylcholine 0.3–1 mg/kg IV; both are individualised. Propofol can raise threshold and shorten seizure. Avoid succinylcholine or use an anaesthetist-planned alternative for pseudocholinesterase deficiency, malignant-hyperthermia susceptibility, major burns/denervation, severe neuromuscular disease or hyperkalaemia risk.[1]

d) Cognition and relapse prevention — 2 marks

9. One mark: disclose acute disorientation and impaired new learning plus possible retrograde/autobiographical memory loss that may persist for an individual; monitor both subjective report and objective cognition rather than promising universal recovery.[3][1]
10. One mark: agree continuation treatment before the acute course ends—optimised illness-specific pharmacotherapy and individualised continuation ECT where relapse history, medication resistance, preference and tolerability support it; there is no compulsory weekly–fortnightly–monthly schedule.[1]

Subtotal: 2/2. Total: exactly 10/10. Each numbered atom scores once only; do not cross-credit the same statement between parts.[1]

References

1. [1]Thirthalli J, Sinha P, Sreeraj VS Clinical Practice Guidelines for the Use of Electroconvulsive Therapy Indian Journal of Psychiatry, 2023.PMID 37063631
2. [2]Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology Journal of Psychopharmacology, 2023.PMID 37039129
3. [3]Semkovska M, McLoughlin DM Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis Biological Psychiatry, 2010.PMID 20673880